Rating for a Change
Cardiac surgeons have agreed to provide data to Consumer Reports for a new physician ratings system.
Guest commentary from Darius Tahir, Vineeta Vijayaraghavan and Jason Hwang of Innosight Institute, a non-profit think tank focused on health care and innovation.
While multiple stakeholders continue to bicker over what health care reform should look like, there was recently a small, but potentially significant, opening move that went largely unnoticed: Cardiac surgeons agreed to provide specific data to Consumer Reports to facilitate a new physician ratings system. Included in the data were metrics associated with better outcomes for patients undergoing heart surgeries. Rating doctors has proven difficult and controversial in the past, but it is a necessary step toward ensuring greater accountability among providers and helping patients make well-informed decisions regarding their own care.
What is uncontroversial is that doctors, like any other group of professionals, come in better and worse forms. And some of those worse forms can be very bad indeed, making egregious medical errors in diagnosis and treatment, while their patients often remain unaware until a dangerous pattern develops and is eventually uncovered.
Other doctors aren't bad in the sense of making mistakes, but the dominant fee-for-service system in American health care -- which tends to reward quantity of care, rather than quality -- encourages them to over-treat their patients. As an illustration, a study in the 1960s revealed that 7 percent of children in one Vermont county had undergone tonsillectomies, while in a neighboring county that was similar in almost every respect, 70 percent of children had their tonsils removed. The difference was that the latter county simply had doctors that more aggressively performed tonsillectomies, many of which were likely medically unnecessary.
And while the facts aren't quite as stark in every instance, ongoing research confirms that large variations persist in care delivery and health care spending across towns and states for reasons unrelated to the underlying health of their citizens. That unwarranted spending makes the system more expensive for all of us, and any solution to rising costs must involve greater accountability in the system for quality and spending.
Though a consumer-oriented physician ratings system like the one being developed by Consumer Reports has yet to capture a large audience, insurers have already begun using similar ratings to reward providers that optimize quality at a lower cost. Doctors that fail to achieve high enough ratings could be excluded from insurers' networks, or patients that wish to continue seeing them will be asked to pay a greater share of the bill. Meanwhile, patients who switch to physicians with high ratings receive the most favorable discounts offered by the plan. As WellPoint Vice President Dick Salmon said in a recent interview with The Wall Street Journal, "End of the day, some physicians do provide higher quality or more efficient care, and it makes sense to provide modest incentives for choosing that care." Research conducted at Innosight Institute by the authors of this commentary reflects this trend: One of our study subjects, HealthPartners, an integrated hospital insurer in Minnesota, offers tiered pricing in which its highest-rated doctors are accessible at lower prices for patients.
Historically, doctors have raised multiple concerns about ratings systems: unfair penalties for taking care of sicker patients, judgments based upon criteria that are too subjective or beyond a health provider's control, and general skepticism that physician performance can be accurately measured. The biggest threat, however, may be the frequent suggestion that ratings be tied to compensation. Dr. Kent Carr, senior vice president of physician services at Lancaster General Health in Pennsylvania, noted, "Physicians are not used to having their compensation at risk; they feel we can't really distinguish quality. For example, smoking patients may be badgered by physicians and then give low quality scores." Indeed, a study published in October 2010 in the Journal of the American Medical Association declared that "whom doctors care for can have as much of an influence on pay-for-performance rankings as what those doctors do."
And then there's another problem with any ratings system: It can be gamed. In the past, physicians could "cherry pick" healthier patients to boost their performance measures. As ratings become more sophisticated, however, these opportunities will become harder to find. Adjustments for severity of illness, for example, have become a standard component of most ratings systems to prevent physicians from "firing" their older, sicker patients and electing to see only younger, healthier patients.
Difficult issues remain unresolved, and ratings systems will need to undergo constant evaluation and improvement. But there is encouraging evidence from early implementations. The Cardiac Surgery Reporting System introduced in New York in the 1990s led to declines in risk-adjusted mortality rates among both high- and low-scoring providers, improving care across the board. Simply making physician performance metrics public was enough to induce improvements in quality.
Beyond the fear and uncertainty that accompany such significant change is the fact that we need a health care system that better aligns the incentives of providers and their patients. Such a system doesn't simply penalize ineffective doctors, but also rewards good physician performance by steering patients to them. To get there, we must begin rating physicians accurately and make those reports available to patients. Though other hurdles remain, such as building a ratings system that is comprehensible to patients and giving patients appropriate incentives to utilize the ratings information, we are in the midst of making a giant leap toward a high-quality, sustainable health care system.
Dr. Jason Hwang is executive director of Innosight Institute; Vineeta Vijayaraghavan is a senior research fellow at Innosight Institute; Darius Tahir is a health care researcher with Innosight Institute.